It is clear that the troubled passage of the Health and Social Care Bill reflects real concern over the future direction of the health service in England. The British Medical Association (BMA) acknowledges the efforts of Government to listen to and address some of the concerns that have been expressed about the Bill to date. However, we still believe that the government's reform plans pose an unacceptably high risk to the NHS, threatening its ability to operate effectively and equitably, now and in the future. This is why the BMA continues to call for the Bill to be withdrawn or, at the very least, to be subject to further, significant amendment.

We believe there continues to be an inappropriate and misguided reliance on "market forces" to shape services. This is very clear in the general direction of policy travel, such as widening patient choice to 'Any Qualified Provider' (AQP) across a much larger range of services, which has the potential to destabilise local health economies if not carefully managed. It is also implicit in the Bill, which embeds a more central role for choice without a full consideration of the consequences and which creates ambiguity about how the trade-offs between increasing patient choice and ensuring fair access, integrated care and improved efficiency should be managed.

In addition, insufficient thought has been applied to the unintended knock-on effects and long-term consequences of proposals in the Bill, including for medical education and training, public health and the patient-doctor relationship. There is now excessive complexity and bureaucracy associated with changes made to the Bill to counter the lack of proper checks and balances in the original proposals. Furthermore, much detail is still lacking, being left to subsequent regulations and guidance.

All of this is at a time when the NHS is working to find an unprecedented £20 billion in efficiency savings, and when the focus on the changes already flowing from the reforms is creating a noticeable distraction to efforts to ensure and improve the quality of patient care. The risks are high, not least because the long-term effects of the legislation are likely to be extensive. Meaningful, sustainable reform needs to have the full confidence of patients and those working in the health service.

I enclose a detailed briefing ahead of the Commons Report Stage and Third Reading debates highlighting our concerns with the Bill.